Claims HMO - Recalculation Examiner 140-1036

About the role

The Recalculation Examiner researches and reprocesses previously adjudicated claims that require reconsideration across all lines of business. Using resources, knowledge, and decision-making skills, the examiner determines appropriate actions to pay, deny, or adjust claims while meeting performance expectations for accuracy and efficiency.

Responsibilities

• Research and reprocess claims, collaborating with internal departments such as customer service, pricing, provider services, medical management, enrollment, grievance and appeals, and configuration.
• Review corrected claims submitted by providers, verify their validity, and make necessary adjustments or redirect them to processing staff for finalization.
• Perform clerical duties related to processing inquiries, including drafting first-level appeal letters to providers and requesting information for providers, members, or authorizations.
• Research and respond to first-level inquiry appeals received via paper mail.
• Determine overpayment amounts and complete paperwork to request refunds.
• Maintain an inventory tracking log and follow up on claims routed to other areas.
• Interface with various departments to resolve claim corrections, research/re-adjudication projects, and potential system issues.
• Identify and communicate trends or problems encountered during the adjudication process.
• Resolve unique problems or situations independently, without supervisor involvement.
• Contribute to a positive working environment with peers and other departments.
• Stay updated on changes related to claims processing, benefits, limits, and regulations.
• Perform other duties as assigned.

Requirements

• Self-motivated with the ability to work with minimal direction.
• Ability to read and understand claims processing manuals, medical terminology, CPT codes, and perform claims processing procedures.
• Knowledge of claims processing manuals and health benefit booklets.
• Understanding of contracted managed care plan terms and rates for multiple lines of business.
• Successful completion of a Health Care Sanctions background check.
• Proficiency in Microsoft applications.
• Ability to perform basic mathematical calculations.
• Demonstrated learning agility.
• Knowledge of Network Authorization requirements.
• High attention to detail.
• Strong oral and written communication skills.
• Ability to organize time effectively, set priorities, and meet deadlines.

Qualifications

High school diploma or equivalent required. Three years of related work experience in claims processing, data entry, or medical billing. One year of claims processing experience within CommunityCare or another healthcare environment is required.